In the pharmaceutical industry, drug manufacturers often establish what is known as a Average Wholesale Price (“AWP”), or AWP, for individual products (e.g., drugs). The AWP is the price assigned to a drug (e.g., brand name or generic) and is currently listed in the Red Book, First DataBank and/or Medispan, which are data source providers that provide drug information related services and monitor current drug information. AWP is a commonly used price index in pharmaceutical transactions. State Medicaid Agencies use AWP to calculate payments to retail pharmacies for providing drug products to Medicaid patients. Prescription benefit managers (PBMs), insurance carriers (which may include a group of insurance carriers, referred to by a Bank Identification Number or “BIN,” administering claims on behalf of one or more insurance carriers), and managed care organizations (MCOs) use the AWP for a particular drug to determine the appropriate reimbursement amount to pay a retail pharmacy who fills their customer's prescriptions for that particular drug. Pharmacies often use AWP as a cost basis for pricing their prescriptions to patients, such pricing of a drug by an individual pharmacy is referred to as the Usual and Customary (“U & C”) price, retail or “cash” price. AWP is not required to reflect the price of any actual sale of drugs by a manufacturer, nor is it defined in law. Rather, drug manufacturers adjust their AWPs fairly often depending on a variety of factors both business related and market related.
Often there is a lag in time between when the drug manufacturers make their adjustments to the AWP for a particular drug and when the insurance processors adjust the AWP values they each use to determine an appropriate reimbursement for that particular drug. As a result, a pharmacy may end up paying a higher purchase price for a particular dug than what they would be reimbursed for by an insurance processor. For example, drug X has an AWP of $5 a pill on January 1st. Drug X's manufacturer increases the AWP of that particular drug on January 15th to $10 a pill. Insurance processor Y updates its AWP databases only on the first of every month. Therefore, a pharmacy submitting a reimbursement claim to insurance processor Y on January 20th will be reimbursed at the $5 a pill rate and not the $10 a pill current market rate.
Such use of outdated pricing values in claim reimbursement may prove costly to pharmacies. Further, delaying claim submissions or dedicating resources for pharmacies to individually monitor their payer's use of pricing values requires unnecessary cost and labor to pharmacies as well. Therefore, what is needed are systems and methods that address these problems of current claim reimbursement systems.